A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

Distended neck veins.

Poor skin turgor.

Concentrated hemoglobin and hematocrit levels.

Decreased urine output.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Fluid volume overload is an excess of fluid in the intravascular and/or interstitial spaces. One of the hallmark signs of fluid volume overload is distended neck veins, which indicates increased venous pressure due to the accumulation of fluid. The neck veins become more visible and prominent, especially when the patient is in a semi-Fowler's position.

Choice B rationale:

Poor skin turgor is a sign of dehydration, not fluid volume overload. It is characterized by the skin's inability to return to its normal position after being gently pinched. In fluid volume overload, the skin may become edematous and puffy, but it does not exhibit poor turgor.

Choice C rationale:

Concentrated hemoglobin and hematocrit levels are seen in conditions of dehydration or hemoconcentration, not in fluid volume overload. In fluid volume overload, there is excess fluid, which may lead to dilutional effects, resulting in decreased concentration of blood components.

Choice D rationale:

Decreased urine output is associated with fluid volume deficit (dehydration) rather than fluid volume overload. In fluid volume overload, there is often an increase in urine output as the body tries to eliminate the excess fluid.

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Correct Answer is C

Explanation

Choice A rationale:

Hypocalcemia refers to low levels of calcium in the blood, which can present with symptoms like muscle cramps, numbness, and tingling. However, this choice is not relevant to the patient's symptoms in the scenario.

Choice B rationale:

Hypercalcemia is an electrolyte imbalance characterized by high levels of calcium in the blood. It can lead to ECG changes and symptoms like muscle weakness, confusion, and constipation. However, this is not the correct answer in the given scenario.

Choice C rationale:

The patient's symptoms of ECG changes and muscle weakness are consistent with hyperkalemia. Spironolactone is a potassium-sparing diuretic, and its use can lead to increased potassium levels in the blood (hyperkalemia), which can affect the heart's electrical activity and cause muscle weakness.

Choice D rationale:

Hypokalemia is a condition where there is a low level of potassium in the blood. It can lead to muscle weakness, ECG changes, and other symptoms, but it is not the correct answer in this specific situation involving spironolactone use.

A. Respiratory acidosis. B. Metabolic acidosis. C. Metabolic alkalosis. D. Respiratory alkalosis.

Correct Answer is A

Explanation

Choice A rationale:

The arterial blood gas results show a low pH (acidosis) and an elevated Paco2 (partial pressure of carbon dioxide), which indicates respiratory acidosis. This condition occurs when there is inadequate removal of carbon dioxide through ventilation, leading to an accumulation of carbonic acid in the blood and a decrease in pH.

Choice B rationale:

Metabolic acidosis would present with a low pH and a low bicarbonate (HCO3-) level, not an elevated Paco2.

Choice C rationale:

Metabolic alkalosis would present with a high pH and an elevated bicarbonate (HCO3-) level, not an elevated Paco2.

Choice D rationale:

Respiratory alkalosis would present with a high pH and a decreased Paco2, not an elevated Paco2 as seen in this case.

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A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

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Naxlex Comprehensive Predictor Exams

A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which electrolyte imbalance?

Correct Answer is C

Explanation

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a Paco2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Correct Answer is A

Explanation

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

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?

A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

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 nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

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.).