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

Concentrated hemoglobin and hematocrit levels

Distended neck veins

Decreased urine output

Poor skin turgor

Answer and Explanation

The Correct Answer is B

Choice A: Concentrated hemoglobin and hematocrit levels are not a sign of ﬂuid volume overload, but rather of ﬂuid volume deficit. This is a condition that occurs when the body loses more ﬂuid than it gains. This can happen in patients who have excessive bleeding, vomiting, diarrhea, or diaphoresis. Concentrated hemoglobin and hematocrit levels indicate hemoconcentration, which is an increase in the ratio of blood cells to plasma.

Choice B: Distended neck veins are a sign of ﬂuid volume overload, because this condition occurs when the body retains more ﬂuid than it excretes. This can happen in patients who have heart failure, kidney failure, or excessive ﬂuid intake. Distended neck veins indicate increased central venous pressure, which is a measure of the pressure in the right atrium of the heart.

Choice C: Decreased urine output is not a sign of ﬂuid volume overload, but rather of oliguria or anuria. These are conditions that occur when the urine output is less than 400 mL or 50 mL per day, respectively. These can happen in patients who have acute or chronic kidney injury, urinary obstruction, or shock. Decreased urine output indicates impaired renal function and decreased glomerular filtration rate.

Choice D: Poor skin turgor is not a sign of ﬂuid volume overload, but rather of dehydration. This is a condition that occurs when the body loses more water than it gains. This can happen in patients who have fever, diabetes insipidus, or hyperglycemia. Poor skin turgor indicates decreased skin elasticity and delayed return to normal shape after being pinched.

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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.

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 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 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

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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