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. Sodium 165 mEq/L B. Potassium 5.2 mEq/L C. Urine specific gravity 1.020 D. Hct 62%

Correct Answer is C

Explanation

Choice A: Sodium 165 mEq/L is incorrect. This value indicates hypernatremia, which is a high level of sodium in the blood. Hypernatremia can be caused by dehydration, but it does not indicate that the client is responding to treatment. A normal sodium level is between 135 and 145 mEq/L.

Choice B: Potassium 5.2 mEq/L is incorrect. This value indicates hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can be caused by dehydration, but it does not indicate that the client is responding to treatment. A normal potassium level is between 3.5 and 5.0 mEq/L.

Choice C: Urine specific gravity 1.020 is correct. This value indicates that the urine is concentrated, but within the normal range. Urine specific gravity measures the amount of solutes in the urine compared to water. A high urine specific gravity indicates dehydration, while a low urine specific gravity indicates overhydration. A normal urine specific gravity is between 1.005 and 1.030.

Choice D: Hct 62% is incorrect. This value indicates polycythemia, which is a high level of red blood cells in the blood. Polycythemia can be caused by dehydration, but it does not indicate that the client is responding to treatment. A normal hematocrit (Hct) level is between 37% and 52% for men and between 32% and 47% for women.

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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?

Nursing Test Bank

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 caring for a client who is receiving IV ﬂuids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is eﬀectively responding to treatment?

Correct Answer is C

Explanation

A nurse is assessing a client who has ﬂuid volume deficit. The nurse should expect which of the following findings?

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.)

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The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

A patient is diagnosed with hypokalemia. After reviewing the patient's current medications, which drug should the nurse consider that might have contributed to the patient's health problem?

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is eﬀective, the nurse should expect which of the following changes on the client's ECG?

A patient's blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse realizes that the patient is demonstrating which acid-base disorder?